PEDIATRIC ANESTHESIA SOCIETY FOR PEDIATRIC ANESTHESIA
SECTION EDITOR
WILLIAM J. GREELEY
The Development and Validation of a Risk Score to Predict
the Probability of Postoperative Vomiting in
Pediatric Patients
L. H. J. Eberhart, MD*, G. Geldner, MD*, P. Kranke, MD†, A. M. Morin,
A. Schäuffelen, MD‡, H. Treiber, MD‡, and H. Wulf, MD*
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*Department of Anesthesia and Intensive Care, Philipps-University, Marburg; †Department of Anesthesiology and
Intensive Care, University of Würzburg, Würzburg; and ‡Ambulatory Surgical Center Söflingen, Ulm, Germany
Risk scores to predict the occurrence of postoperative
vomiting (PV) or nausea and vomiting that were devel-
oped for adult patients do not fit for children, because sev-
eral risk factors are difficult to assess or are usually not
applicable in pediatric patients (e.g., smoking status).
Thus, in the present study, we sought to develop and to
validate a simple score to predict PV in children (POVOC-
score). Development and validation of the new score was
based on data from 4 independent institutions of 1257
children (aged 0 –14 yr) undergoing various types of sur-
gery under general anesthesia without antiemetic pro-
phylaxis. Preoperatively, several potential risk factors
were recorded. Postoperatively, the occurrence of PV was
observed for up to 24 h. The dataset was randomly split
into an evaluation set (n ⫽ 657) that was analyzed using a
forward logistic regression technique and a validation set
D
uring the last decades, life-threatening compli-
cations associated with anesthesia have be-
come very rare. This safety record has encouraged
anesthesiologists to focus attention on minor morbidity.
Of these, postoperative nausea and vomiting (PONV) is
one of the “big little problems” after general anesthesia
(1). PONV may decrease parental satisfaction, increase
the use of resources, including medical and nursing care,
IV fluids, drugs, and other supplies (2–5). Furthermore,
in the ambulatory setting, PONV is a major cause of
unanticipated admission (6).
The incidence of this distressing problem can be re-
duced by using a total IV anesthetic (TIVA) technique
Financial support was provided by institutional sources only.
Accepted for publication May 26, 2004.
Address correspondence and reprint requests to Leopold Eber-
hart, MD, Department of Anesthesia and Intensive Care, Philipps-
University, Baldingerstr. 1, D-35033 Marburg, Germany. Address
e-mail to eberhart@mailer.uni-marburg.de.
DOI: 10.1213/01.ANE.0000135639.57715.6C
1630 Anesth Analg 2004;99:1630–7
MD*,
(n ⫽ 600) that was used to confirm the accuracy of predic-
tion by means of the area under a receiver operating char-
acteristic curve. Four independent risk factors for PV were
identified in the final analysis: duration of surgery
ⱖ30 min, age ⱖ3 yr, strabismus surgery, and a positive
history of PV in the children or PV/postoperative nausea
and vomiting in relatives (mother, father, or siblings). The
incidence of PV was 9%, 10%, 30%, 55%, and 70% for 0, 1,
2, 3, and 4 risk factors observed. Using these incidences as
cut-off values in the validation dataset, the area under the
receiver operating characteristic curve was 0.72 (95% con-
fidence interval: 0.68 – 0.77). Our data suggest that PV can
be predicted with an acceptable accuracy using a four-
item simplified risk score.
(Anesth Analg 2004;99:1630 –7)
instead of inhaled anesthetics and by administering an-
tiemetics prophylactically. However, routine efforts to
prevent PONV are not indicated because of the potential
for adverse effects, the perception that there are in-
creased costs, and the lack of evidence that patient sat-
isfaction is affected (7).
For these reasons, tools to predict an increased risk
for developing nausea and vomiting are certainly use-
ful in clinical practice. Several scores have been devel-
oped for adults. However, their use in pediatric pa-
tients is limited, because several of the proven risk
scores for adults are difficult to assess or not applica-
ble to children. For example, nonsmoking and a his-
tory of PONV after previous anesthesia are known
risk factors for PONV in adults. Obviously, there are
only a few children younger than 14 years old who
smoke and fewer children presenting for elective sur-
gery have had a previous anesthesia compared with
an adult population and are thus more often errone-
ously classified as having a “negative” history of post-
operative vomiting (PV).
©2004 by the International Anesthesia Research Society
0003-2999/04
ANESTH ANALG
2004;99:1630 –7 PREDICTION OF POSTOPERATIVE VOMITING IN CHILDREN (POVOC-SCORE)
Thus, the aim of this analysis was also to create a
simplified model1 to facilitate the prediction of POst-
operative VOmiting in Children (POVOC-score).
Methods
Data Collection
The data of 1401 children (0 –14 yr old) included in this
prospective survey were collected during a period of
22 mo at 2 university hospitals, a community chil-
dren’s hospital, and an outpatient surgical center. The
local ethics committee approved the study and the
parents gave informed written consent.
Preoperatively, the following data were obtained
from the parents: history of PV or motion sickness in
the child, history of PONV in the mother, the father, or
in any siblings, preoperative anxiety of the child. The
children were fasted 2– 4 h preoperatively from clear
fluids and at least 6 h from milk and solids. All re-
ceived oral premedication with midazolam. If no con-
traindications were present, the children received a
non-opioid analgesic (acetaminophen, metamizole,
and/or diclofenac) intraoperatively or immediately
after operation. The first oral intake was allowed de-
pending on the length and site of operation. In most
cases (90%), this was within the first 4 h postopera-
tively. Because of the observational character of the
study, the anesthesia technique was not standardized
but was performed according to the local standards
(Table 1).
Using the anesthesia recordings, the following data
were extracted: age, sex, weight, height, type of induc-
tion (volatile versus IV), duration of anesthesia and
surgery, type of surgery, type and dosage of anesthet-
ics drugs, and additional measures (regional blocks,
nasogastric tubes, etc.).
Postoperatively, vomiting or retching (PV) was as-
sessed in the postanesthetic care unit by specially in-
structed nurses or anesthesiologists. PV was chosen as
the main end-point of the survey, because nausea is a
subjective phenomenon, and the smaller child often
may not be able to describe it (9). Twenty-four hours
postoperatively, the children and/or their parents
were interviewed. Additionally, all medical records
were screened and the nursing staff was asked in
order not to miss an emetic episode. The parents of
patients having surgery on an outpatient basis were
interviewed by telephone using a structured interview
on the first postoperative day.
1
In this context, a “simplified score” means that the predicted risk
can be directly derived by counting the number of identified risk
factors without further calculations. Previous validation of PONV
scores for adult patients have demonstrated identical and even
improved predictive properties of those “simplified” scores (8).
PEDIATRIC ANESTHESIA EBERHART ET AL. 1631
Preprocessing of the Data
To reduce the amount of variables for the final anal-
yses, several clinical data (e.g., administration of any
muscle relaxants, opioids or non-opioid analgesics
separated according to intra- and postoperative ad-
ministration, or the use of any local or regional anes-
thesia performed intraoperatively) were simplified
and collapsed into separate dichotomous variables.
Weight and height were used to calculate the body
mass index that was used for further analysis. Type of
surgery was classified mainly according to the fre-
quency, the anatomical location, and the complexity of
the surgery (Table 2). The main outcome data (inci-
dence of PV during the first 24 h) were dichotomized
into nonvomiters and vomiters.
Of the1401 children that were observed, 88 receiv-
ing a prophylactic antiemetic, including corticoste-
roids, were withdrawn from the analysis. A further 56
patients were lost for follow-up or were excluded
from analysis because of incomplete recordings. The
remaining 1257 patients were randomly split into
an evaluation dataset (n ⫽ 657) and a validation set
(n ⫽ 600).
Creation of the Statistical Models
The evaluation set was subjected to stepwise forward
logistic regression analysis using the maximum likeli-
hood function. To allow the model to compensate for
nonlinearity with regard to the influence of continu-
ous variables (age, duration of anesthesia, duration of
surgery), these data were also dichotomized (14
groups with intervals of 1 yr for age 0 –1, 0 –2, 0 –3 yr
etc., and each 8 groups for duration of surgery and
anesthesia with 15-min intervals, respectively). Both,
the continuous variables and the dichotomized values
were offered to the logistic regression analysis. The
goodness of fit of a model was judged using
Nagelkerke’s R2. All analyses were performed using
SPSS 11.0 for Windows. The factors included in the
initial model were used to calculate the probability of
vomiting for each child of the validation dataset. The
discriminating properties of a predictive model were
investigated by calculating the area under a receiver
operating characteristics (ROC) curve. This graph can
be constructed by correlating true- and false-positive
rates (sensitivity and 1 minus specifity, respectively)
for a series of cut-off points for a test in which the
cut-off point is the predicted risk. The area under the
curve (AUC) represents the probability that a random
pair of test results will be ranked correctly as to their
disease state (10). Theoretically, a 45° bisector would
be a score predicting not better than a random guess.
Thus, the area under this “random score” would be
0.5. A score performing significantly better than
chance has an AUC ⬎0.5 with the lower limit of the
95% confidence interval exceeding the value of 0.5 (8).
1632 PEDIATRIC ANESTHESIA EBERHART ET AL. ANESTH ANALG
PREDICTION OF POSTOPERATIVE VOMITING IN CHILDREN (POVOC-SCORE) 2004;99:1630 –7

Table 1. Patient Characteristics of the 1257 Children Included in the Statistical Analysis
Boys 796 (63.3)
Girls 461 (36.7)
Age (yrs) 6 (4; 9)
Height (cm) 117 (103; 134)
Weight (kg) 20 (16; 31)
Body mass index (kg 䡠 m⫺2) 15.9 (14.6; 17.9)
Children with previous surgery 377 (30.0)
Children with previous surgery and previous postoperative vomiting 70 (18.6% of 377)
Children receiving postoperative opioids 118 (9.4)
Duration of surgery (min) 40 (20; 70)
Duration of anesthesia (min) 60 (45; 95)
Inhaled induction of anesthesia 289 (23.0)
Using sevoflurane 165 (13.1)
Using halothane 124 (9.9)
Induction of anesthesia by IV injection 968 (77.0)
Using thiopentone 444 (45.3)
Using propofol 519 (41.3)
Using methohexitone 2 (0.2)
Using ketamine 3 (0.2)
Maintenance of anesthesia
Using halothane 387 (30.8)
Using enflurane 193 (15.4)
Using isoflurane 144 (11.5)
Using sevoflurane 98 (7.8)
Using desflurane 263 (20.9)
Using propofol 172 (13.7)
No intraoperative opioid administration 399 (31.7)
Opioid supplementation
Using fentanyl 287 (22.8)
Using alfentanil 503 (40.9)
Using remifentanil 68 (5.4)
No neuromuscular blocking drug 510 (40.6)
Neuromuscular blockade
Using vecuronium 305 (24.3)
Using atracurium 289 (23.0)
Using rocuronium 108 (8.6)
Using suxamethonium 45 (3.6)
Airway device
Endotracheal tube 655 (52.1)
Laryngeal mask 424 (33.7)
Face mask 178 (14.2)
Additional regional anesthesia
None 1019 (81.1)
Infiltration/field blocks 189 (15.0)
Caudal block 49 (3.9)
Normal distributed data are shown as arithmetic means and standard deviation, otherwise as median and 25th and 75th percentile (in parentheses).

Adjustments of the Initial Risk Model Results

Because our aim was to create a simplified score that
can be easily calculated by counting the number of
unweighed risk factors present in an individual pa-
tient, several modifications and adjustments were
made in the initial (basic) model. These are ex-
plained step-by-step in detail in the Results section.
Each adjustment of the risk model was accompanied
by a subsequent calculation of Nagelkerke’s R2 as a
measure of the goodness of fit of the regression
model and by calculating the area under the ROC
curve for the validation set.
Initial (Basic) Risk Model
When all available data (including the dichotomized
continuous variables of “age,” “duration of surgery,”
and “duration of anesthesia” were entered into the
first logistic regression analysis, seven risk factors
were included in the model (Table 3). Nagelkerke’s R2
(⫽0.271) showed acceptable goodness of fit. The AUC
of the ROC curve was 0.76 (95% confidence interval:
0.72– 0.80) when the score was applied to the evaluation
dataset. However, from the practical point of view,
this first model was found to be too complex and was
ANESTH ANALG
2004;99:1630 –7
Table 2. Types of Surgery Performed in 1257 Children
Included in the Statistical Analysis
Otorhinolaryngology surgery
Adenectomy (⫹myringotomy)
Adenotonsillectomy
Tympanoplasty
Others
Ophthalmic surgery
Strabismus surgery
Others
Urologic surgery
Orchidopexy
Circumcision
Others
Abdominal surgery
Inguinal hernia repair
Major abdominal procedures
Orthopedic surgery
Dental procedures
Diagnostic procedures
Plastic/aesthetic surgery
Miscellaneous procedures
Total number of surgeries performed
Children with 2 types of surgery
Children with 3 types of surgery
Children with ⱖ4 types of surgery
Numbers are presented as absolute and relative incidences.
not compatible with the predefined aim of the study to
create a simplified model.
First Adjustment of the Risk Model
In this step, the information about the previous expe-
riences of PV by the patient and of PV/PONV by the
relatives [both were significant risk factors with an
odds ratio (OR) of 2.6 and 1.4, respectively] were
grouped by using a Boolean “OR” connection. Fur-
thermore, age was removed because it was the only
continuous variable in the basic risk model. Multipli-
cation of the actual age of a patient with the coefficient
complicates a risk model and counteracts the intention
to create a model that is easy to use. While running a
subsequent logistic regression analysis, “age” (OR
in the basis model: 1.057 per year) was substituted
by the variable “8 yr or older” (OR of the dichoto-
mous variable: 1.5).
Combining the two variables on anamnestic infor-
mation whether PV/PONV had been present in the
child or its relatives had an OR of 3.7 that is approx-
imately the product of the two previous ORs (Table 3).
To further reduce the number of variables, it was
decided to replace the variable “duration of anesthesia
longer than 90 min” by the duration of surgery, be-
cause duration of anesthesia and surgery are obvi-
ously highly correlated (quantified by the equation:
duration of surgery ⫽ 0.941 * duration of anesthesia ⫺
14.6 min; R2 ⫽ 0.982; P ⬍ 0.0001). Thus, the variable
PEDIATRIC ANESTHESIA EBERHART ET AL. 1633
PREDICTION OF POSTOPERATIVE VOMITING IN CHILDREN (POVOC-SCORE)
“anesthesia longer than 90 min” was replaced by “du-
ration of surgery longer than 75 min.” A subsequent
462 reanalysis of the data revealed that the goodness of fit
212 of the regression model was only slightly affected
114 (Nagelkerke’s R2 ⫽ 0.252) as were the predictive prop-
92 erties when the model was applied to the validation
44 dataset (AUC value of 0.73 (0.68 – 0.75).
177
165
12 Second Adjustment of the Risk Model
296
130 After the first adjustment of the model, there were two
104 factors that were present in duplicate. Increasing age
62 of the child undergoing surgery shows a two-stage
159 increase of the risk to vomit postoperatively. In the
128 present model, these two levels were age of 3 (OR:
31 2.707) and 8 yr or older (OR: 1.463), respectively. The
68
71
same applies for the duration of surgery, where
43 30 min (OR: 2.535) and 75 min of duration (OR: 1.895)
66 were determined as a critical period in this dataset. It
33 was decided to manually remove the less predictive
1375 variable of these two factors because of three major
63 reasons. First, from a practical point of view, it seems
20 reasonable to further reduce the amount of risk factors
5 that need to be remembered by the anesthesiologist
when applying such a score. Second, “age of 8 yr and
older” and “duration of surgery longer than 75 min”
both were the weakest predictors for PV in the model.
Third, removing one variable of a two-step risk factor
strengthens the remaining variable in the model. For
example, children 8 yr or older will also increase the
odds of PV in children in the group of 3 yr and older.
The same applies for the duration of surgery. The
results of this step are given in Table 4.
Third (Final) Adjustment of the Risk Model
To meet the predefined aim to develop a simplified
model, where the risk of PV can be calculated by
simply counting the number of risk factors, the coef-
ficients were finally removed from each risk factor.
Because the risk factors all had ORs approximately
between 3 and 4, no relevant alteration in predicting
properties was expected. Using the evaluation dataset,
the observed incidences for the presence of 1, 2, 3, and
4 risk factors were determined. These were 9%, 10%,
30%, 55%, and 70% for 0, 1, 2, 3, and 4 risk factors
observed. Using these incidences as cut-off values in
the validation dataset, the area under this ROC curve
was 0.72 (95% confidence interval: 0.68 – 0.77). All
ROC curves for this and for the previous initial and
intermediate risk models are plotted in Figure 1.
Discussion
A recent evaluation of risk scores that was created for
adult patients has shown that none of the investigated
risk models was suitable for children (11). As pointed
1634 PEDIATRIC ANESTHESIA EBERHART ET AL. ANESTH ANALG
PREDICTION OF POSTOPERATIVE VOMITING IN CHILDREN (POVOC-SCORE) 2004;99:1630 –7

Table 3. Results of the Initial Logistic Regression Analysis in Which All Available Variables, Including the Dichotomized
Derivates of the Continuous Data (Age, Duration of Surgery, and Anesthesia) Were Included
95% Confidence
␤ Coefficient se of ␤ P value OR interval of the OR
Strabismus surgery 1.649 0.201 ⬍0.0001 5.200 3.509–7.708
Age (per year) 0.055 0.026 0.032 1.057 1.005–1.112
Age ⱖ3 yr 0.862 0.273 0.002 2.368 1.386–4.048
Duration of anesthesia ⬎90 min 0.636 0.182 ⬍0.0001 1.889 1.322–2.699
Duration of surgery ⬎30 min 0.935 0.170 ⬍0.0001 2.548 1.826–3.556
History of PV in the child 0.957 0.277 0.001 2.604 1.512–4.484
History of PV/PONV in the father, mother, or siblings 0.356 0.145 0.014 1.428 1.076–1.896
Constant ⫺3.080 0.263 ⬍0.0001
Nagelkerke’s R2 was 0.265 and the area under the receiver operating characteristic curve (and its 95% confidence interval) for patients of the validation dataset
were 0.76 (0.72– 0.80).
OR ⫽ odds ratio, PV ⫽ postoperative vomiting; PONV ⫽ postoperative nausea and vomiting.

Table 4. Results of the Logistic Regression Analysis in Which Duplicate Risk Factors (Each with Two Levels) Were
Reduced to One Dichotomous Information (age ⱖ3 yr; Duration of Surgery ⬎30 min)
95% Confidence
␤ Coefficient se P value OR interval of the OR
Strabismus surgery 1.465 0.196 ⬍0.0001 4.327 2.945–6.357
Age of ⱖ3 yr 1.204 0.229 ⬍0.0001 3.334 2.130–5.218
Duration of surgery ⬎30 min 1.179 0.155 ⬍0.0001 3.252 2.400–4.408
History of PV in the child or history of PV/PONV in 1.445 0.342 ⬍0.0001 4.241 2.168–8.296
the father, mother, or siblings
Constant ⫺2.786 0.241 ⬍0.0001
This model is the basis for the final adjustments in which the coefficients were removed to achieve a simplified score. Nagelkerke’s R2 ⫽ 0.250; area under
the curve ⫽ 0.71 (95% confidence interval: 0.67– 0.74).
OR ⫽ odds ratio, PV ⫽ postoperative vomiting, PONV ⫽ postoperative nausea and vomiting.

out, this is because several risk factors shown to be
relevant in adults are not applicable in most children
(e.g., smoking status).
Comparing risk factors for PV/PONV in adults and
those identified as independent and relevant in the
present study can give interesting insights in the eti-
ology of PONV.
Age
Younger age is a risk factor that was identified in
adults (12). However, there is good evidence from
clinical trials that toddlers are less susceptible to
emetic stimuli than school children and adolescents
(13). Our findings support the latter observation.
Around the age of three years, the risk to develop PV
increases dramatically. This is represented by an OR
of 2.4 in the initial model. Furthermore, there was a
continuous increase of PV in the children with increas-
ing age. The OR per year was 1.057 that is (depending
on the presence of other risk factors) an increase of
0.2%– 0.8% per year. This aspect of the influence of age
on the occurrence of PV was not included in the final
model in order to keep it simple and easy to use in
clinical practice. Manually removing the continuous
variable “age” subsequently strengthened the factor
“age 3 years and older” that had an OR of 3.3 in the
final model and thus reaches the impact of other im-
portant predictors of PV in children.
Strabismus Surgery
There is a continuing debate about whether the type
or the site of surgery influences the occurrence of
PONV in adults. There are risk scores in which
several types of surgery were identified as risk fac-
tors [e.g., Sinclair et al. (14)]. However, there is also
good evidence that in a large majority of patients
the observed frequent (e.g., females undergoing gy-
necological laparoscopies) or infrequent incidence
(e.g., elderly men undergoing transurethral resec-
tions of the prostate) of PONV in adults can be
explained with biometric and anamnestic risk fac-
tors. Thus, most of the established and validated
risk scores do not include any type of surgery in
their risk model. In children, we came to a very
similar conclusion. Most surgery does not have an
influence on PV, even though this might have been
expected by theoretical pathophysiological consid-
erations (e.g., middle ear surgery is often considered
to be a risk surgery). However, our analysis re-
vealed that strabismus surgery was an independent
risk factor for PV. It was the most significant pre-
dictor with an OR of 5.2 in the basic and 4.3 in the
ANESTH ANALG
2004;99:1630 –7 PREDICTION OF POSTOPERATIVE VOMITING IN CHILDREN (POVOC-SCORE)
Figure 1. Receiver operating characteristics (ROC) curve for the
initial and the final risk model (solid lines). The dotted curves
represent intermediate adjustments made during the evolution of
the initial risk modeling.
final adjusted model. This result is in agreement
with findings in a systematic review on antiemetic
prophylaxis in children undergoing strabismus re-
pair where an extraordinary frequent incidence (up
to 87%) could be observed in several trials (15).
Duration of Surgery
The duration of surgery and anesthesia respectively
have an impact on PV symptoms (12,14,16). Al-
though the exact pathophysiological background is
still unknown, there is a rational biological basis.
The longer an emetic stimulus (e.g., administration
of volatile anesthetics and opioids) is present, the
more likely it is that this trigger leads to nausea and
vomiting.
Previous PV/PONV
The positive history of PONV is an unequivocally
accepted risk factor for further PONV symptoms at
future anesthesia (14,16 –18). Thus, it was not surpris-
ing to notice that this was also the case in children.
More interesting is that children with parents or sib-
lings who have experienced PV or PONV after a pre-
vious anesthesia are at increased risk. The question is
whether this family association with PV/PONV is
genetically or behaviorally determined. There is some
evidence in the literature that genetic aspects might be
involved. For example, monozygotic twins have more
PEDIATRIC ANESTHESIA EBERHART ET AL. 1635
frequent congruent behavior with regard to develop-
ing PONV than heterozygote twins.2
Factors Not in the Initial Model
There were several potential risk factors for PV in our
patients that were not statistically significant in the
present trial and thus were not included in the basic
risk model. However, reviewing them might give in-
teresting insights into the etiology of PV in children.
For this purpose, an explorative backward logistic re-
gression analysis was performed. The factors that
were removed during the last steps of this analysis
and thus are most likely to affect PV in children are
listed in Table 5.
Administration of Local or Regional Anesthesia
Administration of local or regional anesthesia is an
important measure to reduce the intensity of postop-
erative pain and to improve postoperative recovery
and well-being after surgery. Moreover, these tech-
niques also seem to positively influence the occur-
rence of PV. Although not significant in the statistical
analysis (P ⫽ 0.065), they should be taken into account
as a part of a multimodal approach to reduce the
incidence of PV.
In our analysis, all types of locoregional techniques
were grouped into one dichotomous variable to obtain
an adequate statistical power for the variable. This
means that wound infiltration of the surgical site as
well as caudal blocks and peripheral nerve blocks,
which were performed in some complex orthopedic
surgery along with general anesthesia, were repre-
sented within one variable.
The mechanism for the potential antiemetic effect of
performing locoregional anesthesia in children re-
mains speculative. When performed intraoperatively,
a locoregional block reduced the need for opioids and
also for large doses of volatile anesthetics that were
shown to be a main cause for PV during the early
stage of recovery (19). During the postoperative pe-
riod, these blocks can reduce the need for postopera-
tive opioids.
Intraoperative Administration of Opioids
The use of intraoperative opioids showed a tendency
to reduce the incidence of PV, which seems at first
surprising. Most procedures that were performed
without the use of opioids were short-lasting proce-
dures, e.g., adenectomies or myringotomies. How-
ever, the multivariate analysis revealed that omission
2
Reavley CM, Cherkas L, Spector TD, MacGregor AJ. Genetic
factors contribute to the risk of postoperative nausea and vomiting:
results of a twin study. Br J Anaesth 1999;82(Suppl):1–2.
1636 PEDIATRIC ANESTHESIA EBERHART ET AL.
PREDICTION OF POSTOPERATIVE VOMITING IN CHILDREN (POVOC-SCORE)
Table 5. Factors That Were Not Included in the Initial Risk Model
␤ Coefficient
Administration of local or regional ⫺0.543
anesthesia
Intraoperative opioid administration ⫺0.520
Postoperative opioid administration 0.492
Female gender 0.230
Surface surgery ⫺0.284
Only the five most important factors are listed. These were determined by an explorative backward logistic regression analysis using the maximum likelihood
function.
OR ⫽ odds ratio.
of opioids is not the reason for the infrequent inci-
dence of PV in these types of surgery but it is the
surgery’s short duration. One possible explanation for
the (nonsignificant) PV-reducing effects of using intra-
operative opioids might be their dose-sparing effect
on volatile anesthetics (19).
Postoperative Administration of Opioids
It is not surprising that the administration of postop-
erative opioids had a tendency to increase PV, because
opioids are known to cause PONV. In two of four risk
scores for PONV in adults, the administration of opi-
oids was an independent and statistically significant
predictor for the occurrence of these symptoms (16,20).
Female Gender
Previous studies have shown that even in older chil-
dren, gender does not have a major role in the occur-
rence of PV (21). In our trial, gender was removed but
was the eleventh strongest predictor in the backward
regression analysis. Similar to adults, female patients
are (not significantly) more prone to PV. It can be
speculated that this result is because some girls were
included in the analysis that were already at the age to
menstruate. This view is supported by the fact that an
interaction term between age (11 years and older) and
female gender was a better predictor than female gen-
der alone.
Limitations of the Risk Model
One major limitation of our study and our results is
that the underlying population does not represent all
potential heterogeneity of clinical practice seen in an-
esthesia as well as in all surgical specialties. As a
consequence, techniques that were under-represented
in our dataset had no chance to be a significant risk
factor or protective factor. As an example, there were
only 54 children who had received TIVA. Thus, TIVA
had no chance to show its antiemetic properties in this
analysis, although it is known from several previous
clinical studies and quantitative systematic reviews
that propofol used for induction and maintenance of
ANESTH ANALG
2004;99:1630 –7
95% Confidence interval
se P value OR of the OR
0.281 0.065 0.581 0.331–1.032
0.310 0.080 0.595 0.347–1.094
0.366 0.139 1.636 0.838–3.52
0.150 0.126 1.259 0.938–1.691
0.212 0.180 0.753 0.497–1.140
anesthesia reduces the incidence of PV/PONV (22,23).
Another example is the types of surgery that were not
surveyed in our trial (e.g., neurosurgical, cardiac sur-
gical). Thus, on one hand, the results of our analysis
only apply for anesthesia techniques, types of surger-
ies, and perioperative management of the patients
who were described in the Methods section and in
Tables 1 and 2. On the other hand, our data were
collected in four different centers working indepen-
dently and with different local standards. Thus, re-
sults from our analysis can be better transferred to
other institutions than a score derived from a single
center.
Another potential criticism of our study might be
the preprocessing of the data before entering the lo-
gistic regression analysis. While combining and di-
chotomizing the data, several simplifications were
made that could have affected the final results. For
example, all IV induction drugs used during the sur-
vey were merged into one dichotomous variable and
grouped against all other children in whom anesthesia
was induced by inhaled halothane or sevoflurane. On
one hand, this procedure eliminates potentially valu-
able information but, on the other hand, it is the only
possibility to create variables with adequate statistical
power to “survive” in the logistic regression model.
Another example for this dilemma— grouping all the
heterogeneous techniques of local, regional, and cen-
tral regional blockades in one variable— has been dis-
cussed previously.
Another problem in this context is that even vari-
ables that seem to be perfectly defined are not homog-
enous. For example, “strabismus surgery” summa-
rizes different surgical approaches (with or without
myopexy) that might all have different emetogenic
potential (24).
Other problematic aspects of the statistical model-
ing are potential interactions between the individual
factors. Logistic regression is not the optimal statistical
tool for complex interaction analysis. Furthermore, it
has been recommended that such interactions should
only be examined when there is a biological rationale
ANESTH ANALG
2004;99:1630 –7 PREDICTION OF POSTOPERATIVE VOMITING IN CHILDREN (POVOC-SCORE)
for a potential interaction. As an example, an interac-
tion term “age older than 11 years” and “female gen-
der” provides more information than each of the
single variables alone.
Comparison of the Predictive Properties of the
Initial Basic Risk Model and the Finally
Adjusted Simplified Risk Score
When comparing the initial risk model with its 7 items
and the final simplified risk score with 4 variables,
there was a statistically significant decrease in the
predictive properties of the model (measured by the
area under the ROC curve) from 0.76 to 0.72. How-
ever, from the clinical point of view, this decrease is of
minor importance (16).
As in previous risk models to predict the incidence
of nausea and vomiting in adults (8,25), it is of great
importance that risk models can be used easily in
clinical practice to guarantee widespread use and ac-
ceptance by clinicians. In this context, two criteria are
important: First, there should be as few factors as
possible that must be remembered when the score is
applied to a patient. Second, the recorded risk factors
must be easily transferable to the patient’s individual
risk. This is the case only if no complicated calcula-
tions are needed. The score that used this approach
was presented by Koivuranta et al. (16), who reported
interesting details about their approach to simplify the
predictive model. For example, they did not observe a
relevant reduction in the discriminating power of their
model when the number of factors was reduced from
8 (prediction of PONV) or 10 (prediction of PV) to the
final 5 factors. Furthermore, eliminating the coeffi-
cients for each factor and simply summing up their
numbers resulted in nearly identical AUC values for
the model.
We conclude that the occurrence of PV in children
can be predicted using a duration of surgery longer
than 30 minutes, age ⱖ3 years, strabismus surgery,
and a positive history of PV in the children or PV/
PONV in relatives (mother, father, or siblings) as ma-
jor predictors.
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